RU2733994C1 - Method for reposition of intraarticular bone fragments of shinbone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to traumatology and orthopedics. After performing the surgical approach to the area of the intraarticular fracture of the shinbone, prior to repositioning the intraarticular fragments, under the X-ray control parallel to the articular surface in the crosswise direction, the pins are introduced. Further, a hole is formed in the cortical layer of the bone with a chisel, and an articular fragments is repositioned through the hole by an impactor resting on the support reinforced surface created from the wires. Wires are introduced deeper into the adjacent fragment for temporary fixation. Impactor is removed. That is followed by osteosynthesis with metal structures, wires used for temporary reinforcement are removed.

EFFECT: method enables reducing a bone defect volume, reducing intraoperative injuries, reducing the need for bone repair defects, to preserve the blood supply of the fracture region, to reduce the operation time and to reduce the intensity of postoperative pain syndrome due to the set of methods of the declared method.

1 cl, 2 ex

Description

The proposed invention relates to medicine, in particular to traumatology and can be used for the treatment of intra-articular fractures of the tibia.

According to statistical reports, diaphyseal fractures of the lower leg bones rank first among the damage to the long bones. Every year in the United States for these injuries conducted 825 000 examinations and 77,000 hospitalizations of patients [Praemer A., Furner S., Rice D.P. Musculoskeletal conditions in the United States. - Park Ridge, IL: American Academy of Orthopedic Surgeons. - 1992.].

The frequency of fractures of the proximal tibia is from 2 to 5% among all fractures of the musculoskeletal system, as well as from 6 to 12% among all intra-articular fractures [Gilev M.V. Surgical treatment of intra-articular fractures of the proximal tibia. - The genius of orthopedics. - 2014. - No. 1. - S. 75-81.]

Intra-articular fractures of the tibia are an extremely difficult problem, since during treatment it is necessary to achieve the most accurate reduction of the articular surfaces in order to restore their congruence.

According to the literature, the incidence of unsatisfactory outcomes in the treatment of intra-articular fractures of the tibia ranges from 10 to 54%. One of the main causes of complications is insufficiently accurate reduction and consolidation of fragments in the wrong position.

As a result of incomplete elimination of the displacement, the congruence of the joint is disturbed, a circulatory-metabolic imbalance occurs, hypoxia of paraarticular tissues develops, metabolites accumulate, which, as a result, contributes to the development of scar tissue at the site of injury. Further changes that develop in the surrounding tissues lead to fusion of the surface of the synovial membrane with the surface of the bone and contribute to the formation of fibrous ankylosis and the progression of post-traumatic arthrosis [Voronkevich I.A. Fractures of the proximal epiphysis of the tibia and the technical capabilities of modern submerged osteosynthesis. - Traumatology and Orthopedics of Russia. - 2004. - No. 1. - S. 68-75.].

The difficulty in repositioning the articular surface of the tibia is due to its anatomical features - the spongy structure of the bone, the complex shape of the articular surface, and the difficulty of visualization. To improve the results of treatment and select the optimal treatment tactics, it is necessary to determine the number, size and exact location of bone fragments, to identify the degree of destruction of the tibial plateau, knowledge of the anatomical and biomechanical features of the knee joint is required.

In most cases, during the injury, the bone is impressed and after the restoration of the anatomical position of the joint surface, a defect is formed. This is facilitated by a decrease in the bone mineral density of the epimetaphyseal area of the tibial condyles, which cannot at the time of traumatic impact withstand the more durable femoral condyles [Horwitz D.S., Bachus K.N., Craig M.A., Peters C.L. A biomechanical analysis of internal fixation of complex tibial plateau fractures. - J. Orthop.Trauma. 1999. 13 (8). - P. 545-49.].

The conservative method of treatment with prolonged immobilization of the limb leads to the frequent development of functional disorders, is associated with the difficulty of maintaining reduction, the need for frequent control radiographs and repeated examinations, and often the restoration of joint congruence simply cannot be achieved conservatively [Digby J.M., Holloway G.M., Webb J.K. A study of function after tibial cast bracing. - Injury. - 1983. - 14. - P.432 - 439.].

Osteosynthesis with external fixation devices, in most cases, is used for open fractures, or, for the purpose of temporary immobilization. The main disadvantages of using this technique are local inflammatory complications, delayed union and incorrectly consolidated fractures, household discomfort of patients [Anglen J.O. Early outcome of hybrid external fixation for fracture of the distal tibia. - J. Orthop.Trauma. - 1999. - 13. -P.92 - 97.].

Wide open reduction leads to an increase in postoperative complications. In addition, when attempting a mechanical direct reduction (by impactors, conductors, etc.), additional iatrogenic “crushing” of the cancellous bone occurs, which can significantly increase the volume of the defect and complicate the reduction. In this regard, minimally invasive methods of osteosynthesis and reduction come out on top.

To perform accurate reduction, adequate visualization of the intra-articular fracture area is required; for this purpose, intraoperative X-ray control is used. At the same time, due to the complex anatomical configuration of the tibial condyles, the image of the monitor of the electron-optical converter does not always allow to adequately assess the quality of reposition of the articular surfaces.

To control the fracture zone, a number of authors suggest using arthroscopic control. At the same time, this technique does not affect the method of reposition of bone fragments and does not lead to a decrease in the bone defect formed by pressure with instruments on the cancellous bone.

The known "Method for repositioning intra-articular fractures of the calcaneus" [RU 2 192 798, C2, publ. November 20, 2002, IPC А61В 17/56 (2000.01)]. This method is based on the introduction of an awl through the Achilles tendon under the fragments of the articular surfaces of the calcaneus, then the fragments are raised with an awl from bottom to top, while using the calcaneal tubercle as a fulcrum, displacing it down, reposition and form the normal Beller angle. The awl is removed. Osteosynthesis is performed.

The closest to the proposed method of reposition of intra-articular fractures of the tibia is "Method of closed reduction of bone fragments in intra-articular fractures of the tibial condyles" [RU 2 625 651, O, publ. 17.07.2017., IPC А61В 17/56 (2006.01)] including the reposition of bone fragments in intra-articular fractures of the tibial condyles, for which the injured limb is placed on a support when the knee joint is bent at an angle of 165 °, the introduction of two fixing elements into each bone fragment , between the outer ends of which another fixing element is transversely located and firmly fixed with universal clamps of the external fixation rod apparatus. With the assembled structures under X-ray control, the bone fragments are moved to the desired position until a single line of the articular surface of the damaged and undamaged areas of the tibial condyles is obtained on the X-ray image.

The disadvantages of the known methods are:

[RU 2 192 798, C2, publ. 20.11.2002, IPC А61В 17/56 (2000.01)] - 1) impossibility of matching intra-articular fragments of the tibia using an awl; 2) the impossibility of preserving the bone structure in the area of the fracture;

[RU 2 625 651, C1, publ. 17.07.2017., IPC А61В 17/56 (2006.01)] - 1) difficulties in repositioning individual intra-articular fragments due to the need to fix the entire tibia; 2) impossibility of direct reduction without additional compression of the bone; 3) lengthening the time of surgical intervention due to the need to apply an external fixation device;

The technical result of the proposed method for reposition of intra-articular bone fragments of the tibia is:

1. Decrease in the volume of the bone defect formed when trying to reposition the cancellous bone;

2. Reducing the invasiveness of surgery;

3. Reducing the need for bone grafting of defects;

4. Preservation of the blood supply to the fracture area;

5. Reducing the intensity of postoperative pain syndrome;

6. Reducing the operation time;

The method of reposition of intra-articular bone fragments of the tibia is carried out as follows: the operation is performed under anesthesia. After processing the operating field, an incision is made in the fracture area after performing surgical access to the fracture area of the proximal tibia, X-ray control is performed, before reposition of intra-articular fragments, under X-ray control, the needles are inserted parallel to the articular surface in a cross direction in order to temporarily reinforce the cancellous bone, then a hole is formed in the cortical layer of the bone with a chisel through which the impactor with an emphasis on the support surface created from the spokes is used to reposition the articular fragments, the spokes are inserted deeper into the adjacent fragment to maintain the position of the articular fragments, the impactor is removed from the hole, after which the main fragment is repositioned and osteosynthesis with metal structures is performed , the spokes used for temporary reinforcement are removed.

X-ray control of the quality of reduction and location of fixing structures is performed.

Clinical example. Patient D., born in 1986, was admitted with a diagnosis of a closed intra-articular comminuted fracture of the proximal tibia of the left leg with displacement. Household injury, falling from a bicycle. On admission in the area of the right knee joint, moderate swelling, palpation pain, limb support ability is impaired, the symptom of patella ballotation is positive. Angioneurotic disorders were not identified. Radiography and computed tomography of the right knee joint were performed. For the purpose of immobilization, a plaster cast was applied. In 2 days from the moment of admission, the operation was performed: closed reduction, minimally invasive osteosynthesis of the proximal tibia of the right tibia with screws, a plate with angular stability. During the operation, in order to reposition the intra-articular fragment, the reposition method was used using a wire temporary reinforcement of the cancellous bone. Bone grafting of the defect was not performed.

On control radiographs, the position of the metal structures, bone fragments is correct, the joint is congruent.

The postoperative period was without complications, the wounds healed by primary intention, the sutures were removed on the 9th day. The patient was activated on the 1st day after the operation, walking on crutches was allowed without loading the right lower limb. On control radiographs after 12 weeks, secondary displacement of bone fragments was not detected, consolidated fracture of the proximal part of the right tibia. The patient moves without additional support, there is no pain syndrome.

Clinical example. Patient M., born in 1982, was admitted with a diagnosis of a closed intra-articular multifragile fracture of the proximal tibia of the right tibia with displacement. Household trauma, falling from a ladder, 1.5 meters high. First aid, radiography, plaster immobilization were performed on an outpatient basis. On admission to the hospital in the area of the right knee joint, there was moderate swelling, the symptom of patella ballotation was slightly positive, movements and sensitivity of the toes were preserved. Additionally, computed tomography of the injured knee joint was performed. 3 days after admission, the operation was performed: closed reduction, minimally invasive osteosynthesis of the proximal tibia of the right tibia with a plate with angular stability, screws. During the operation, in order to reposition the intra-articular fragment, a reposition method was used using a temporary wire reinforcement of the cancellous bone. Bone grafting of the defect was not performed.

On control radiographs, the position of the metal structures, bone fragments is correct, the joint is congruent.

The postoperative period was without complications, the wounds healed by primary intention, the sutures were removed on the 8th day. Active and passive movements in the knee joint are allowed on the first day after surgery, without loading along the axis of the limb. On control radiographs after 10 weeks, no secondary displacement of bone fragments was detected, the fracture was consolidated. The patient moves without additional means of support, there is no pain syndrome at the time of examination.

Claims (1)

The method of reposition of intra-articular bone fragments of the tibia, based on the introduction of the needles in the cross direction, characterized in that after the surgical access to the area of the intra-articular fracture, before repositioning the intra-articular fragments, under X-ray control, the needles are inserted parallel to the articular surface in the cross direction, in the cortical layer bones are formed with a chisel, through which the impactor with an emphasis on the supporting reinforced surface created from the spokes is used to reposition the articular fragments, the spokes are inserted deeper into the adjacent fragment for temporary fixation, the impactor is removed, after which the osteosynthesis is performed with metal structures, the spokes used for temporary reinforcement are removed.